Purpose:

Activation of latent tuberculosis (TB) has been associated with tumor necrosis factor inhibitor (TNFi) use. As a result, screening with tuberculin skin testing (TST) is recommended prior to initiating treatment with biologic response modifiers (BRMs). However, compliance with this recommendation is imperfect. The electronic health record (EHR) can be leveraged to measure and improve compliance. We conducted a quality improvement (QI) project using the EHR and other interventions to increase the proportion of patients with Juvenile Idiopathic Arthritis (JIA) screened for TB prior to the start of BRMs.

Method:

During January 2010 to May 2010 we conducted a QI initiative employing "Plan, Do, Study, Act" (PDSA) cycle improvement ramps. Baseline data from March 2008 to December 2009 was obtained by querying the EHR for all patients who initiated a BRM, the date of TST placement, and whether a result was reported. During the project's first three months, we developed non-EHR based interventions which included: Introduction of a log to track patients who had a TST placed, development of a patient instruction sheet and TST results card, and initiation of reminder phone calls 4048 hours after TST placement. Rheumatology providers completed a weekly survey of new BRM starts to ensure that no eligible patients were missed. At the end of the third project month, the intervention was modified to include an EHR based best practice alert (BPA) instructing physicians to confirm the placement of a TST each time a BRM is ordered. An EHR BPA is a pop-up box programmed into the EHR with a reminder and an order that satisfies the alert. The outcome measure was the proportion of patients who received a TST with documentation of results within 180 days of BRM start.

Results:

Our baseline data spanned a period of 21 months. There were 247 eligible patients identified; of these, 65 (26.3%) had both a TST placed and resulted. During the 3 month period of non-EHR based interventions, 30 eligible patients were identified, 60.0% of which had both a TST placed and resulted. After the EHR BPA was activated 9 patients were identified in six weeks, 8 (88.9%) of which had TSTs ordered and resulted. A t-test comparing non-EHR based interventions to baseline was significant at p<.001. A t-test comparing the EHR BPA phase to the non-EHR phase generated a p=0.225.

Conclusion:

We observed a statistically significant improvement in the proportion of patients with JIA screened for TB prior to the start of BRMs compared to baseline during the non-EHR portion of our QI project. Further improvements were seen once the EHR BPA was activated. Additional time and patients will be required to determine if the improvement with the EHR BPA intervention reaches conventional levels of statistical significance. We conclude that the use of EHR in conjunction with non-EHR based interventions may be an effective tool to improve the proportion of JIA patients screened for TB prior to the start of BRMs.